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Full text of "Diseases Of The Nose Throat And Ear"

100                 THE PHARYNX AND NASOPHARYNX

Temperature is raised, the pulse rate is increased and there may be profuse
sweating.

CLINICAL FEATURES. On examination there is a marked congestion and
swelling of the pharyngeal mucosa and the uvula is oedematous. The cervical
glands are enlarged and tender. The inflammatory oedema may spread to the
larynx to give rise to hoarseness and later to airway obstruction if the condition
is not treated. At other times infection may spread to the submandibular region
where it causes a hard brawny cellulitis (Ludwig's angina). In some cases the
infection may involve the lungs, the pleura or the pericardium.

TREATMENT. The patient should be confined to bed until convalescent. A
throat swab is taken for sensitivity of the organisms, and until the results are
available a wide-spectrum antibiotic, such as ampicillin, should be prescribed.
This may be given intramuscularly until swallowing is easier, and a total daily
dosage of 1-3 g should be administered to the adult in divided doses. When
the patient is able to swallow the appropriate antibiotic is given in full
dosage for at least 5 days. This must be insisted on because there is a tendency
for the patient to discontinue treatment when the symptoms abate. Dehydra-
tion is frequently a problem and copious nutritious fluids should be ordered.
If swallowing is impossible the patient should be hospitalized and given
intravenous infusions.

If airway obstruction threatens, as evidenced by stridorous breathing, the
patient should be treated in hospital where frequent pulse and respiratory rate
readings and the results of blood gas analysis may suggest that tracheostomy
is necessary. The onset of Ludwig's angina will also call for hospitalization in
case incision and drainage should prove necessary. These two severe complica-
tions of septic pharyngitis are less. common than formerly provided that
antibiotic treatment is given vigorously and early in the disease, but they may
occur in a patient living alone and unable to summon early medical advice.

ACUTE MEMBRANOUS PHARYNGITIS

Acute membranous pharyngitis or Vincent's angina is a highly infectious and
ulcerative lesion of the tonsils. It was common during the first World War, being
called trench mouth, and the frequency with which it occurred was probably
due to lack of hygiene in the cleaning of eating and drinking utensils. It is now
much less common. The infection is caused by two Gram-negative organisms,
a fusiform bacillus and a spirochaete, which can be isolated together from the
ulcers. Vincent's infection may contaminate malignant lesions of the mouth
and 'pharynx.

SYMPTOMS. The patient has a low pyrexia and complains of a sore throat.
The cervical glands may be enlarged. Constitutional symptoms are slight.

CLINICAL FEATURES. Usually only one tonsil is involved, but the membrane
may often spread on to the gums and the soft and hard palate. The typical
lesion.presents as a greyish slough (Plate V> 1) which bleeds easily when it is
removed to reveal a deep ulceration of the tonsil. The membrane re-forms after
removal. There is a characteristic smell from the breath. The infection may
persist for several weeks if untreated, but should clear up in a week with
appropriate therapy.

DIAGNOSIS. A swab from the arTected area will show the causative organisms.
Differentiation is from other diseases which produce a membrane—diphtheria